Preface
Tuberculosis-damaged lung refers to destructive and extensive changes in the lung lobes, such as single or multiple caseous cavities or tuberculous fibrous cavities, limited bronchiectasis, mediastinal displacement, pleural adhesion thickening, and loss of lung function due to repeated infection with Mycobacterium tuberculosis [1]. Most patients suffer from irreversible damage to lung tissue due to untimely clinical diagnosis of tuberculosis, or failure to provide reasonable treatment after diagnosis, prolonged treatment and recurrent attacks [2]. The poor results of antituberculosis treatment in nodular destructive pulmonary medicine and the unsatisfactory results of surgical treatment such as lesion removal have increased the difficulty of clinical treatment [3].
1.Materials and methods
1.1 Clinical data
1.1.1 General data were selected from 138 patients with tuberculous disfigured lung admitted to our hospital from June 1985 to October 2010, including 77 males and 61 females, aged 12-64 years, with an average age of 36.5±4.2 years. The duration of tuberculosis disease was 2-19 years, with an average of 7.9±3.8 years. There were 76 cases of left destroyed lung and 62 cases of right destroyed lung. All patients had recurrent chest pain, hemoptysis, fever, coughing up purulent sputum and wasting of varying degrees. Patients with contraindications to surgery such as severe liver and kidney insufficiency, acute inflammation, and hematologic disorders were not included.
1.1.2 Preoperative examination
Preoperative routine examinations: preoperative chest x-ray and CT examination, sputum smear or culture (drug resistance examination for positive cases), blood routine, coagulation function, blood sedimentation examination; heart, lung, liver and kidney function examination, etc.
1.1.3 Preoperative symptoms
There were 102 cases of cough, 69 cases of coughing sputum, 32 cases of blood in sputum, 29 cases of hemoptysis, 31 cases of chest tightness, and 24 cases of fever. Sputum tuberculosis bacilli were positive in 22 cases (15.94%) as shown in Table 1. There were 64 cases of primary treatment patients and 74 cases of retreatment patients. The average anti-tuberculosis treatment for the whole group was 26.2±1.9 months. Treatment regimen: rifampicin 0.45g once daily orally, isoniazid 0.3g once daily orally, ethambutol 0.75g once daily orally, pyrazinamide 0.5g three times daily during the consolidation period. During the consolidation period rifampicin 0.45g once daily orally, isoniazid 0.3g once daily orally, ethambutol 0.75g once daily orally. The duration of treatment is usually 12 months or more.
1.2 Surgical method
All patients were operated with double-lumen endotracheal intubation and under general anesthesia. Through the 4th or 5th intercostal incision into the chest, the adhesions between the lung and the surrounding tissues were separated alternately by blunt and sharp, and in patients with heavy adhesions, extrapleural separation was performed and effective hemostasis was achieved, and then the arteries and veins of the patients’ lung tissues were treated separately, and the proximal ligated vessels were ligated and sutured afterwards. The bronchial-bronchial stump was freed, and suture ligation with sutures or disposable bronchial closure was performed. The bronchial stump is encapsulated with a pericardial piece or mediastinal pleura. The surgical trauma surface is examined, hemostatic and sutured. If necessary, the chest tube is double ligated between the inferior pulmonary vein and the diaphragm, and the chest is finally closed after placement of closed chest drainage [2]. In this group, 62 cases of right total pneumonectomy and 76 cases of left total pneumonectomy were performed, and the operation time was 1.9-7.5h.
1.3 Efficacy observation and follow-up
All patients were followed up for a minimum of 12 months after surgery, and medical records were collected for retrospective analysis to summarize and analyze factors related to efficiency and complications after surgery.
1.4 Statistical analysis
All data were analyzed by applying SPSS16.0 statistical software, and the measurement data were expressed by `x±s.
2, Results
All 138 patients underwent successful total pneumonectomy, including 62 cases of right total pneumonectomy and 76 cases of left total pneumonectomy. The average bleeding volume of this group was 1136 ml, the average operation time was 4.2 h, and the average hospital stay was 38 d. All patients were treated with more than 3 types of anti-tuberculosis drugs after surgery, and the treatment time was more than 1 year.
2.1 Basic situation of surgery in drug-resistant patients
There were 12 drug-resistant patients whose drug resistance was shown in Table 2. The average surgical blood loss was 770 ml, and within 1 year of postoperative follow-up, 10 patients were cured and 2 died 3 months after surgery. The causes of death: 1 case of hemorrhagic shock and 1 case of respiratory failure.
2.2 Major complications after total pneumonectomy
The total number of postoperative complications after total pneumonectomy in the whole group of patients was 23 (16.67%) (see Table 3), including 2 cases of respiratory failure, which were cured after 3-30 days of treatment. There were 3 cases of active intra-thoracic hemorrhage, 2 cases were cured after timely surgical hemostasis, and 1 case died. There were 7 cases of abscess chest, all of which were cured by closed drainage of the chest cavity. Four cases of bronchopleural fistula were cured by medical adhesive plugging. Two cases of contralateral pulmonary tuberculosis spread, which were cured by anti-tuberculosis. Cardiac arrhythmias were treated by medication in 3 cases. Other infections in 2 cases were cured by adequate chest drainage, anti-tuberculosis and anti-inflammatory treatment.
2.3 Operative mortality rate
As shown in Table 4, the total mortality rate of our clinical surgery patients within 12 months was 3.62%, and there were 5 cases of death within 12 months after surgery, 2 cases within 3 months after surgery, 3 cases within 4-12 months, 2 cases died of intra-thoracic hemorrhage, and 3 cases died of respiratory failure. Among them, 3 cases died of left-sided resection and 2 cases died of right-sided resection.
2.4 Analysis of factors related to surgical complications and death
There was no statistical difference in the multifactorial analysis of the variables related to surgical complications and death in the whole group (P>0.05).
3, Discussion
Tuberculous destructive lung is a disease caused by long-term chronic tuberculosis infection with fibrosis to solid lung, which is an irreversible lesion, and is treated with drugs in internal medicine, which are not easy to reach effective concentration and easily lead to recurrent infection or hemoptysis and other symptoms during treatment, resulting in the spread of Mycobacterium tuberculosis and the involvement of contralateral lung tissue or normal lung tissue, resulting in lung function decompensation [5]. Surgical treatment is particularly important because tuberculous destructive lung drugs do not achieve effective treatment results. Total pneumonectomy for destructive lung is a more traumatic procedure and has high complications, with 7.5% mortality and 33% complications reported in the literature [6].Massard et al [7] reported that 25 cases of total pneumonectomy had 4% mortality, 12% bronchopleural fistula and 32% pustular chest. Therefore, we should fundamentally develop a reasonable surgical plan to reduce the risk of surgery and decrease the occurrence of postoperative complications.
Indications for total pneumonectomy for destroyed lung: multi-drug resistant tuberculosis with good lung function on one side and ineffective regular anti-tuberculosis treatment on the other side.
And with the following symptoms.
1. Patients with repeated and repeated major coughing up of blood;
2, Patients with abscess chest or bronchopleural fistula;
3, extensive bronchial stenosis due to endobronchial tuberculosis. For the surgery, a double-lumen endotracheal tube with general anesthesia was used to prevent intraoperative aspiration of the healthy side of the lung, and no aspiration of the healthy side of the lung occurred in the whole group. It was found that a median sternal incision reduces postoperative complications [8], but at the same time increases postoperative risk [9]; therefore, the choice of a standard posterior lateral incision can satisfy adequate field exposure, which is consistent with most reports in the literature.
Total pneumonectomy for tuberculous destroyed lung can achieve satisfactory clinical cure rate and sputum conversion rate with low complication rate and mortality rate, which objectively achieves the purpose of improving patients’ quality of life and saving their lives, and therefore has high clinical application value.